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Etiology of eye redness key in treating ocular disorder


Christopher J. Rapuano, MD, explains how red eye might be something more. Superior limbic keratoconjunctivitis may be identified by lifting the upper lid and having the patient look down.

Chronic complaints of ocular irritation, foreign body sensation, or intermittent redness greater in one eye than the fellow eye may be something as simple as allergic conjunctivitis, dry eye, or blepharitis.

Or, its presence may be indicative of some other ocular disorder that may have significantly different treatments, said Christopher J. Rapuano, MD, chief, Cornea Service, Wills Eye Hospital, and a professor of ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia.

These patients have often seen multiple physicians and been treated with a host of treatments but have yet to show significant improvement in their symptoms.

“This is the type of patient you could see in your office next week,” he said.

In a case example, Dr. Rapuano spoke of a patient who presented with “some blepharitis, some lid thickening,” but nothing that was overtly obvious.

“Lifting the lid, I was a little bit more suspicious,” Dr. Rapuano said, noting there was more redness and inflammation superiorly, and when he had the patient look down, there was evidence of lissamine green staining.

“I did not rub the lissamine green strip on the eye-this was a very, very localized staining of the superior conjunctiva in the patient’s right eye, and a pretty identical superior lissamine green staining in the left eye,” he said. 

Flipping the eyelid showed a “velvety pattern under the upper lid,” leading Dr. Rapuano to a diagnosis of superior limbic keratoconjunctivitis (SLK), which can often present in conjunction with dry eye or blepharitis that usually affects middle-aged females (3-5:1 female to male ratio).


“This is a condition [that is missed] all the time,” he said. “And you’ll continue to miss it if you don’t lift the upper lid and have the patient look down.”

This disorder is easy to overlook, but not hard to diagnose-SLK is typically bilateral, chronic, but is relapsing.

“Symptoms can come and go, often for months or years; it is associated with thyroid disease in about 30% of patients, so once you have the ocular diagnosis, consider a work up to determine if the patient needs to be treated systemically for other issues,” he said, although treating the thyroid disease will not help the SLK.


Unknown etiology

The etiology of SLK is unknown, but is most likely related to a mechanical trauma involving the superior palpebral and lax bulbar conjunctiva that is continually rubbing.

Clinical signs will include hyperemia, a redundance and laxity of superior bulbar conjunctiva, a “lack of luster and positive staining of the superior bulbar conjunctiva-and this is true for lissamine green and rose bengal dyes,” he said.

“In bad SLK you can get filaments and erosions and sometimes a superior pannus,” Dr. Rapuano said.


Treating SLK

There is no one treatment that works perfectly for SLK, Dr. Rapuano said.

Treatment typically includes preservative-free artificial tears, topical antihistamines or mast cell stabilizers, temporary or permanent punctal occlusion, topical steroids, cyclosporine 0.05% to 2% BID to QID, lifitegrast BID, acetylcysteine 10%, and physicians “should consider serum tears,” he said.

But if none of those works, “you can go on to other treatments. We have used silver nitrate solution, not the silver nitrate 0.5% solution-not the sticks-on the superior conjunctiva and superior palpebral and on the bulbar conjunctiva for about 15 to 30 seconds,” he said, although he added the solution is not easy to come by any longer.

Other treatments may include localized cautery to superior conjunctiva, double freeze-thaw cryotherapy, or resection with or without amniotic membrane graft of the superior bulbar conjunctiva.

“My favorite treatment when medical treatment doesn't work which is localized cautery to the superior conjunctiva,” Dr. Rapuano said. “I joke around that this is the PRP of the conjunctiva. Why should the retina folks have all the fun? I just cauterize the involved area and that creates scar tissue that will tighten up the tissue to help the symptoms.”

Christopher J. Rapuano, MD

e: cjrapuano@willseye.org

This article was adapted from Dr. Rapuano’s presentation during Cornea Subspecialty Day at the 2017 meeting of the American Academy of Ophthalmology. He did not indicate a financial interest in the subject matter.


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